Knee Pain

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Key History Components • • • • • • • •

Age of patient Skeletal maturity Occupation Activities Prior trauma Onset: acute, traumatic, or insidious Pain description Aggravating and relieving factors 07/18/09

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Extra-articular causes of knee pain • • • •

Distal iliotibial band syndrome manifesting as lateral knee pain Pes anserinus bursitis or plica of the joint capsule for medial side pain Distal hamstring injury for posterior pain Suprapatellar or prepatellar bursitis, or an anterior proximal tibial stress fracture for anterior knee pain.

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Clues to the differential diagnosis of knee pain • • • •

Ligament Injuries Meniscal Injuries Patellar Injuries Knee inflammation w/o trauma

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Anterior Cruciate Ligament (ACL) •

Mechanism of Injury: Twisting injury while foot is planted, hyperextension, sudden deceleration.  Does not require direct contact.  Patient typically falls to ground after injury and cannot get up without assistance.  Large effusion develops within first few hours.  Patient feels a pop in the knee. 

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Medial Collateral Ligament (MCL) •

Mechanism of Injury: Valgus or external rotation force to knee when foot is planted.  Local medial swelling  Pain on palpation in extension and flexion  Laxity to valgus stress testing  Often caused by an exogenous force 

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Lateral Collateral Ligament (LCL) •

Mechanism of Injury: Varus or internal rotational force with foot planted or hyperextended.  Pain, swelling, laxity on varus stress testing.  Often caused by an exogenous force 

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Posterior Cruciate Ligament (PCL) •

Mechanism of Injury: Posteriorly directed force to tibia with foot plantar flexed or hyperextended.  Absence of depression of proximal tibia toward femur.  Knee may exhibit hyperflexion.  Examples: flexed knee hitting the ground or a car dashboard. 

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Meniscal Injuries • • • • •

Locking, catching, painful clicking, or giving way of knee Joint-line tenderness in 60%-80% of patients Hemarthrosis Diminished range of motion Quadriceps wasting

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Patellar Injuries

• Swelling  Above

patella: joint effusion associated with patellar dislocation  Below patella: prepatellar bursitis  Behind the knee: popliteal cyst

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Baker’s Cyst • • • •

AKA: Popliteal cyst Causes, incidence, and risk factors Baker's cyst is a fluid collection behind the knee. This cyst may be formed by the connection of a normal bursa (a normal lubricating fluid sac) with the knee joint. 

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This type is more common in children. Knee - Case Management

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Baker’s Cyst

Baker’s Cyst (cont.) •

The condition can also be caused by the herniation of the knee joint capsule out into the back of the knee, which is more common in adults.  This type of Baker's cyst is commonly associated with a tear in the meniscal cartilage of the knee. In older adults, this condition is frequently associated with degenerative arthritis of the knee.

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Baker’s Cyst (cont.) •

• •

Nearly one half of Baker's cysts are found in children, where they appear as painless masses behind the knee that are more obvious when the knee is fully extended. A large cyst may cause some discomfort or stiffness but generally has no symptoms. Baker's cysts usually disappear spontaneously, but the time in which they do so is variable.

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Baker’s Cyst •

•

Treatment  Interferential-ES/US (50%)  Arthroscopic surgery to decompress the cyst and treat any meniscal tear may become necessary if the cyst is extremely large or painful.  Aspiration, or draining the cyst with a needle, will decrease cyst size but generally the cyst recurs. Prognosis  

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A Baker's cyst is a benign lesion that will not cause any long-term harm, but can be annoying and painful. Long-term disability is very rare, as most cases improve with time or arthroscopic surgery. Knee - Case Management

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Bursitis-Knee •

• •

The bursa can become fluid-filled and inflamed through repetitive motions that rub, bruise or impact the joint, the bursa or both. Bursitis is usually the result of trauma to the joint. Pressure or excessive exercise can also result in bursitis contributing to the development of this condition.

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Bursitis-Knee (cont.) • Prolonged kneeling or leaning on the knee can be harmful to the joint and are the source of such terms as "clergyman's knee" and "maid's knee."

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Sports and Knee Bursitis • •

•

Runners or participants in sports like basketball or soccer that involve a great deal of running. Volleyball players may be affected by bursitis due to frequent kneeling or diving for the ball that forces repetitive contact of the knee with the ground. Wrestlers may develop bursitis from the continual rubbing of their knees on wrestling mats.

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Diagnosis • • •

The diagnosis of bursitis is made through an examination of the knee which will reveal tenderness and swelling over the bursa. Irritation is often visible as swelling under the skin. In more severe cases, the doctor will manipulate the knee to determine whether the bursa should be aspirated (drained of some of the built-up fluid) to relieve pain.

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Plica • •

A plica is a thin wall of fibrous tissue that are extensions of the synovial capsule of the knee. During fetal development, the knee is divided into three (3) separate compartments.  As the fetus develops these compartments develop into one large protective cavity (synovial membrane).  The majority of people have remnants of these three cavities referred to as a plica.

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Characteristics • • • •

Most often the plica is on the medial (inside) of the knee at the level of the medial femoral condyle. Most individuals are not adversely affected by the presence of plicas. The plica only becomes a problem when the knee is irritated, causing an inflammation in the synovial sack. When the synovium is inflamed, the area of the plica becomes thicker.  This thickened area then begins to catch on the femur as the knee moves.

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Plica Syndrome • • •

This syndrome typically produces pain and swelling, a clicking sensation, locking and weakness of the knee is possible as well. Since the symptoms are similar to symptoms of some other knee problems such as arthritis, meniscus tear or ligament injuries. Diagnosis could be confirmed after all the other knee related entities is ruled out.

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Plica – Location • • • • • •

The plica can be located anywhere in the knee. The exact symptoms will be determined by the plica’s location. The most common location is along the medial (inside) side of the knee. The plica can tether the patella to the femur, be located between the femur and patella, or located along the femoral condyle. Regardless of location the pain is due to the plica catching or being pinched between the patella and femur. If the plica connects the patella to the femoral condyle, symptoms will mimic patello-femoral syndrome.

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Treatment of Plica Syndrome •

The first concern is to decrease the inflammation of the synovial capsule.  

NSAIDS Therapeutic exercises and modalities may also be used to treat the plica. • Iontophoresis (utilizing low intensity electric current to transport medications through skin) • Phonophoresis (using ultrasound to transport medications through skin), and ice are most commonly utilized.

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Rehabilitative exercises should be instituted when the inflammation has been controlled and pain levels are falling.

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Exercises • •

•

Focus on increasing overall quadriceps, hamstring, and calf strength., as well as increasing overall muscular flexibility. Examples of appropriate exercises are: pain-free squats that progress to one-leg squats, side step-ups, closed chain terminal knee extension, and applicable sport-specific exercises. Care should be taken to avoid deep squats as this can increase pain and inflammation. The exercises should be performed utilizing PRE (progressive resistance exercises) principles, gradually increasing load and intensity as pain and inflammation allows.

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Clinical Manifestations: (Medial Plica) • • • • •

Diagnosis of symptomatic plica is made by exclusion; and presence of a plica by itself. Symptoms may mimic those of a torn meniscus (eg. snapping, clicking, & medial joint line tenderness. Anterior knee tenderness may be attributed to the anterior extension of the plica to the fat pad. When thickened, the medial plicae may be palpated just above the joint line. Palpation of the plica may be facilitated by having the patient flex & extend knee while the doctor palpates the medial condyle next to patella.

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Mechanism of Injury • •

•

Patellar fracture: direct blow to anterior knee, avulsion force across the patella, or anterior blow to tibia with foot dorsiflexed. Patellar dislocation (usually lateral): twisting injury in which femur rotates medially with foot planted; direct blow to lateral aspect of knee or to medial edge of patella; may accompany ACL tear. Patellar tendinitis or patellofemoral stress: overuse, jumping, kneeling

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Physical Findings • • •

Fractures, ligament ruptures, and meniscal tears: acute intra-articular effusion within first few hours after injury. Cartilage tear, loose foreign body, rupture of quadriceps or patellar tendon: immediate loss of extension. Fracture of tuberosity of the tibia: inability to bear weight or extend knee after a jump.

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Physical Findings (continued) • • • • •

ACL or meniscal tear, MCL/ACL injury, patellar problem, degenerative joint disease, or loose bodies: collapsing or buckling knee. Ligament tear: popping or snapping sound when injury occurred. Neoplasm in children or the elderly, advanced arthritis, or knee infection: night pain. Ligament injury, fracture or subluxed patella: swelling <12 h after injury. Meniscal tear: swelling >12 h after injury

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Knee Inflammation not associated with Trauma

• Differential diagnosis: Osteoarthritis  Rheumatoid arthritis  Gout  Pseudogout  Infection  Overuse injury 

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Key Findings of the History in Patients with Knee Effusion

•

Finding   

   

 

   

High-velocity collision Inability to immediately bear weight "Pop" occurred with injury Cut or pivot mechanism of injury Knee “give way” Inability to continue participation “Pop” felt or heard with injury Blow to proximal tibia Less instability than ACL tear Squat/kneel associated with a twist Clicking Locking Pain with rotational movement

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Diagnosis  Fracture

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ACL tear

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PCL tear

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Meniscal tear

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Occupational or recreational repetitive movement

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Overuse syndrome

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Fever, chills, intravenous drug use, lack of traumatic injury, recent sexual encounter

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Infectious arthritis